Category Archives: Hospitals

Why Boats?

“She has challenged the legal system and won, she’s confronted environmental crimes, relocated the population of a South Pacific Island contaminated by radiation, provided disaster relief to victims of the 2004 Tsunami in South East Asia, and sailed against whaling, war, global warming, and other environmental crimes on every ocean of the world.”- Greenpeace International

Last week, Friendship grew. Rainbow Warrior II, Greenpeace International’s vessel retired, officially transitioning to her new life as Friendship’s third floating hospital, Rongdhonu. Read more about it here.

You might be asking this question: instead of sustaining hospital boats, which are  more expensive than land hospitals, why doesn’t Friendship just build a hospital in the chars?

Don’t worry. I asked it, too.

Boats are such a pivotal part of char life; many char-dwellers rely on boats for market access, disseminating agricultural goods, fishing and migrating from char to char. If there’s anything you can take away from this blog, it’s that chars aren’t dependable. One char which is there one year might have disappeared the next.  The extensive investment of money and human resources needed to build hospitals, on land or water, shouldn’t be risked in any circumstances. So, why not build a hospital on the mainland then, near the shore, instead of the chars? There is technically at least one hospital in every one of the >500 “upazilas” or counties of Bangladesh. There are mainland hospitals already near the shores, but the reason Friendship intervened in the chars a decade ago still rings true. Many people cannot access the mainland hospitals because they don’t have the money needed to afford transportation.

One could argue that small boats could be disseminated widely to char-dweller families to give them access to mainland opportunities, but having a hospital boat – one that travels to the char-dwellers and addresses their specific needs is a source of pride for many of these char communities. This way, the healthcare comes to them. Think of it this way – most men in the chars can probably, some way or another, find their way to the mainland hospital to seek care in the case of illness. But this journey is obstacle-ridden and almost impossible for women to undertake on their own. With Friendship, this isn’t the case.

Friendship’s floating hospitals travel among the chars, docking in a central, more stable char for 3-4 months at a time to provide healthcare. It’s true, char-dwellers still need some money to travel to the char where the boat is docked, but this is a considerably smaller cost. Additionally, the boat is strategically docked on an island where char-dwellers access markets for food and supplies anyway, so the char network ends up working in their favor.

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NCDs

Came across this interesting article on non-communicable disease in the Daily Star a couple days ago. Check it out here in the Daily Star.

Quite an interesting take on things – and it’s true. A closer look at DALYs (disability adjusted life years, which are a public health indicator of total disease burden) in Bangladesh reveals that NCDs now impose the largest health burden in the country. As the article states, NCDs (inclusive of injuries) accounts for ~61% of disease burden while ~39% is from communicable disease, maternal and child health and nutrition combined.

Policy reflects this as well. Bangladesh’s five-year plan for health identifies cancer, CVD (cardiovascular disease), and diabetes as severe public health problems. But does the policy translate to action? Efforts towards NCD prevention and treatment have been a low national priority for funding and programming in light of the current focus on the MDGs.

We establish global criteria for improving health, which end up defining national public health agendas. It’s unfortunate when the global benchmarks do not reflect the true need of the nation in question; nations are tied down by outside influences that define funding and thus what initiatives can do and what they must focus on.

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Last Char Visit

*August 16, 2011

The boat carried us through the smooth water, to our last char, Kharjani Char. The char is relatively new, only about two and a half years old. Because of this, a permanent FCM hasn’t been assigned to this char of approximately 85 houses and over 700 people above the age of 18.

However, we picked up an FCM from a nearby char to join our crew of health manager, paramedic, translator, and Sareeta Apa on the boat. The FCM would aid the paramedic and conduct the uthan boitak (health meeting) today.

The clinic, a small shack with a side of reed, was only half-full when we arrived. There was a baby on the ground in the front, playing with a piece of trash. A small boy ran past me, brushing past my legs. On his chest, there was a burn mark extending the length of his bottom rib, to match the red color of his shorts.

Later, as I sat with my checklist at the uthan boitak, watching the FCM show women family planning posters, I noticed an old woman about five feet in front of me. She had a kind face, but worn with years, unhappiness deeply planted in her eyes. Protruding from her orange sari, below her chin, was a lump, bigger than the size of my fist.

I leaned over to Sareeta Apa, and asked her if she was here to get it checked out. After the meeting, as patients waited in line to be seen, Sareeta Apa asked. The patient was at the satellite clinic to seek care for headaches, not for the tumor, as she had already been living with the condition for more than three years. Can you imagine? Three years without medical support.

I asked her, through my translator, if she had any pain or trouble swallowing. She had none.  But if it had grown to this size in 3 years, there was no telling when it would reach the point of obstructing her esophagus or larynx. The health manager intervened, telling the patient that we had a hospital where a simple surgery could fix her problem.

She was insistent, shaking her head from side to side. She also said she didn’t have the money to access the boat anyway. As she said this, the two or three young couples who had surrounded us to watch the situation unfold started laughing. I asked what was so funny, and the health manager answered, with a frown, that people were telling the patient she shouldn’t seek treatment because they’ll cut her open and she’ll die on the table. She’s old anyway, there’s no need to spend resources to fix her. Besides, it’s a curse from Allah. There’s nothing we can do to fix it.

I felt my cheeks get red. The discouragement from her fellow community members made her flee the scene as soon as she got her medicine for headaches. She had two sons who kept their distance, I was told. Additionally, I was informed that if she had daughters instead, they would be oppressed and ousted by the community, just like their mother.

Two things were at play here: 1) the fear and social taboo surrounding getting medical treatment in the form of an operation, and 2) cultural beliefs that the sickness was Allah’s will, and that’s it. Both are things that can be addressed with medical treatment coupled with educational outreach. It’s hard for communities to disprove the legitimacy of such operations and treatments once they see their neighbors healed. The hard part is getting those neighbors to get treated in the first place.

What a last visit. I don’t remember feeling this sad, disappointed, and hopeless in a long time. But one thing is for sure – this brought home for me the vitality of having services in communities in addition to our hospital boats. We can create all the hospitals we want – in planes, boats, buses – but if these health facilities are not used by those that they are geared to heal, then our work is wasted. Uthan boitak, our community health meetings, can be used for adding the roots needed to get these patients to view their health in an empowering way. The capacity is there, we just need to scale up, focus, and fortify.

I head home tomorrow morning. The bus will be a good time to process some of these thoughts and transform them into something positive – namely, a rant on the importance of community outreach in my internship report. I should have plenty of time, as bus strikes have gripped the nation by storm right before Eid.

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Why some call me Burcu Bhai

*July 9, 2011

On the mainland right outside of EFH each day, a sizable group of men gather to play football (that’s soccer for my American friends out there) right around sunset. Some of the players are from EFH and others come from around the char. In a weird way, I kind of envy them. More than merely just watching sports, I love participating, even though I may not be very good. I’ve thought about tossing the ball around with them several times, but each time, chose to stay away, reasoning it would be weird to socially insert myself this way. I continued watching and cheering from the dock of the boat.

However, today, I was watching the daily game on the grass with several workers from EFH and behind us, a scene started to unfold. A boat landed, several dozen men got out, and instead of the boat gliding away like usual, all of the men circled it and worked to lift it out of the water and onto the mainland. They chanted as they pushed, drawing attention from everyone surrounding them. I commented how I wish I had brought my camera. One of my colleagues, Hasib Bhai, had come ready – he flipped out his camera phone and started capturing the spirited event, jokingly stating that I had failed as a bideshi and that he wouldn’t share the footage.

I felt odd as a spectator when those I was watching were working so hard. I voiced this uneasiness, too, telling Hasib Bhai how I wish I could help the men. He said, half-teasingly, “Go. Do it. Go and help them.” I thought, a football game is one thing, but collective effort is another.

So I joined in and Hasib Bhai ended up sharing the footage with me. After the push, I got several big, appreciative smiles from some of the men, if not for my actual power, then just for my effort. I think my mom and dad will think it’s funny that my colleagues ended up calling me “Burcu Bhai” for several days after this.*

*Note: The footage is from a camera phone, so you may want to adjust the volume as you’re watching.

Just something fun! Here’s a recap…

  • Minute 0:20: Heated debate about boat-sliding strategy.
  • Minute 0:50: A bit of an awkward moment. All the men are probably thinking, “Umm, what?” or “Did that just happen?”
  • Minute 1:09: Kind words from Hasib Bhai, warning me to be careful because the boat will be slippery.
  • Minute 1:55: Subtle (or maybe not so subtle?) recruitment of men from one side of the boat, to mine.

*FYI- Although this might be a little late in the game, ‘Bhai’ is generally a term used to reference other men in a respective manner, while ‘Apa’ is used in the same way for women.

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I’m on a boat (but no really!)

June 30th, 2011

As a result of a lucky scheduling coincidence, Sareeta Apa and I traveled to Chilmari by seaplane yesterday. The sprawl of Dhaka seemed endless even from a bird eye’s view; not contrary to my expectations – even from the ground, Dhaka seems in a state of perpetual construction, with bamboo supporting most new structures in lieu of metal rims.

Outskirts of Dhaka

My eyes absorbed a beautiful scene of water and green for the sweet flight duration of forty-five minutes. (I say sweet because the bus would have taken 10 hours). Bangladesh is truly more water than land, with the world’s largest delta system and the greatest flow of river water to the sea of any country on earth.

Towards the end of the flight, the thick white of the monsoon clouds engulfed the plane, before they cleared and we started spotting the char islands through our wide windows. Chars are newly emerged lands from the water as a result of accretion, with an unpredictable lifespan ranging anywhere from one to fifty years. In other words, from our plane, it looked as if some larger creature had taken his fingers and run them through the river, creating these unstable, transient islands.

Chars in the distance...

Anyone who visits the country sees that poverty is a pervasive problem in Bangladesh, but with limited land and other natural resources, added to the messy process of erosion and accretion in the river delta, impoverishment in these chars is truly extreme. Rapid erosion of Bangladeshi farmland renders many people landless (two-thirds of the rural population, to be exact), who then move to these newly emerging chars. These settlers lack secure title and can only occupy the chars with the consent of powerful “land grabbers” who illegally control this public land. Of course, without secure title, char-dwellers become discouraged and unwilling to invest in improving their land or houses.

Chars are usually unfavorable for farming due to salinity and flooding and are especially vulnerable to cyclones and storms. The living conditions are harsh, due to lack of clean fresh water and fuel. Moreover, there are very poor communications and minimal services from government and NGOs, because the chars are physically out of reach and well, in a country where even those in sight aren’t tended to properly, out of sight, out of mind takes on a new form. Climate change threatens to make the scenario even more precarious, exacerbating these vulnerabilities with greater probability of cyclones and storm surges, increased rainfall during monsoon, less precipitation in winter, high temperatures, and sea level rise. Char-dweller livelihood will indubitably worsen.

And then, we spotted it – like a beacon in the night, the hospital boat, EFH, docked along an older char. My home for the next 10 or so days.

Emirates Friendship Hospital (EFH) plus other ambulatory boats!

Friendship is one of the first NGOs to get involved in providing services to char-settlers, setting the bar high for NGO involvement here. On top of EFH that provides primary health care and specialized secondary health camps (surgeries, more involved procedures) at almost no cost to patients, Friendship holds satellite clinics twice a month in each of our chars. As an organization, Friendship has trained women from these communities to take on the role of community health workers (FCMs), and its these FCMs, along with trained paramedics from the mainland, that run the satellites to provide primary care, health counseling, behavior education, and family planning services to char communities. It’s these services I’ll be closely observing and then working on tools to help Friendship monitor its progress.

Meeting at the Chilmari field office

We held a meeting today at the Chilmari field office with 10 members of health staff, a conglomeration of the district supervisor, FCMs, paramedics and a paramedic assistant. Our goal was to gain insight on what kind of monitoring is happening on the field presently and note the current gaps and strengths of our community-based services. Like many NGOs meeting imminent needs, Friendship expanded rapidly during its inception in the late 1990s. Retaining many of the intended program components  – like constant monitoring and evaluation – through this scale-up became exceedingly difficult. Our current monitoring is scattered and sporadic at best, so I have my work cut out for me.

After the insights of the meeting, Sareeta Apa and I had a brief conversation about the universality of our field. We had both, once upon a time, cogitated a medical career and stumbled upon public health. After hearing many of the concerns of the FCMs and paramedics, we both agreed. Diagnosing patients, however valuable, seems unsustainable if the larger conditions that create their ailments remain undiagnosed.

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